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Aldosterone SYMPTOMS Unless otherwise noted, the content of this course material is licensed under a Creative Commons Attribution - Non-Commercial - Share Alike 3.0 License. Copyright 2008, Arno Kumagai, Gary Hammer The following information is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. You should speak to your physician or make an appointment to be seen if you have questions or concerns about this information or your medical condition. You assume all responsibility for use and potential liability associated with any use of the material. Material contains copyrighted content, used in accordance with U.S. law. Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarifications regarding the use of content. The Regents of the University of Michigan do not license the use of third party content posted to this site unless such a license is specifically granted in connection with particular content objects. Users of content are responsible for their compliance with applicable law. Adrenal Physiology & Steroid Pharmacology Logo: All Rights Reserved Regents of the University of Michigan. 2008 Gary D. Hammer, M.D., Ph.D. University of Michigan Ann Arbor, Michigan USA Learning Objectives After this lecture you should have an understanding of: • The feedback loops regulating cortisol secretion. • The physiologic actions of glucocorticoids (cortisol) + mineralocorticoids (aldosterone) • The major pharmacologic uses of glucocorticoids. • The major types of glucocorticoids. • The major side effects of glucocorticoid therapy. Anatomy of the adrenal glands Public Domain Wikimedia Commons Public Domain Seers.gov Public Domain Wikimedia Commons Histology of the Adrenal Gland adrenal cortex CC:BY-NC-SA 1.0 BY: Royal College of Surgeons of Ireland (RCSI) adrenal medulla Public Domain Wikimedia Commons Adrenocortical Hormones = Steroids GLUCOCORTICOID MINERALOCORTICOID Cortisol Aldosterone cortex medulla Adrenal Steroidogenesis glomerulosa fasciculata reticularis gonad periphery Public Domain Wikimedia Commons ‘Roids: The Bottom Line In the right amounts, steroids can be the body’s best friend…. or in the wrong amounts, the body’s worst enemy…. Role of Glucocorticoids in Human Physiology In the right amounts, glucocorticoids keep: • Your blood pressure up (maintain cardiovascular stability). • Your blood sugar up (maintain metabolic homeostasis). • Your disposition sunny (maintain integrity of CNS function). • Your temperament cool (regulate response to stress). Adrenocortical Hormones = Steroids GLUCOCORTICOID MINERALOCORTICOID Cortisol Aldosterone cortex medulla Adrenal The HPA axis Neural Stimuli Hypothalamus -- CRF ++ ACTH Anterior Pituitary -- ACTH Plasma Cortisol Concentration Adrenal ++ CC:BY 3.0 BY: Regents of the University of Michigan Regulation of ACTH Expression by CRH Public Domain Bruno Dubuc Post-translational Processing of POMC in the Normal Pituitary POMC = Pro-opiomelanocortin ACTH Source: Undetermined MSH = Melanocyte stimulating hormone ACTH and Steroid Biosynthesis POLYSOME CELL MEMBRANE ATP 3',5' cAMP INACTIVE PROTEIN PROTEIN ACTH ADENYLATE CYCLASE KINASE ACTIVE PROTEIN CHOLESTEROL ESTER STEROID CHOLESTEROL BIOSYNTHESIS Secretion, Transport and Metabolism of Cortisol Image of CNS Control removed Circadian Rhythm of Cortisol Secretion Highest in morning 24 hour period 24 hour period day night day night 20 g/100 ml μ 15 10 5 Plasma Cortisol 0 8 AM 4 PM 12 MID 8 am 4 PM 12 MID Source: Undetermined Lowest in evening Corticosteroid Binding Globulin (CBG) Image of Globulin removed SHBG Grishkovskaya et al, 1999 • Acidic glycoprotein MW 52,000 • Produced in liver, lung, kidney, testes • Regulates delivery of cortisol to tissues Conditions that Affect Cortisol Metabolism • Increased Turnover: --Thyroxine --Barbiturates --Phenytoin • Decreased Turnover: --Liver disease • Increased Binding: --Estrogens Molecular Action of Glucocorticoids Glucocorticoid receptors (GR) are transcriptional activators of a variety of gene products. Image of Glucocorticoid Target Cell removed Metabolic Effects of Glucocorticoids Prototypical Glucocorticoid = Cortisol Glucocorticoids Insulin Glucocorticoids effects are generally opposite those of insulin. Glucocorticoids & Carbohydrate Metabolism GLUCOCORTICOIDS Glucocorticoids increase hepatic (+) Glucocorticoids glucose output decrease insulin sensitivity (-) Liver Glucose (-) MUSCLE (+) INSULIN FAT CELL Glucocorticoid Effects on Protein Metabolism Insulin Glucocorticoids Anabolism (storage) Catabolism MUSCLE Protein synthesis Protein synthesis Protein breakdown Protein breakdown Amino acid release Amino acid release Glucocorticoid Effects on Lipid Metabolism Insulin Glucocorticoids Anabolism (storage) Catabolism Lipid synthesis Lipid synthesis Lipolysis ADIPOCYTE Lipolysis Fatty acid release Fatty acid release Redistribution of fat Redistribution of Fat in Glucocorticoid Excess Image of patient removed Central obesity seen in Cushing’s Syndrome (Glucocorticoid Excess) Glucocorticoid Effects on Inflammatory Mediators Glucocorticoids INHIBIT inflammation. Inhibit: 1) Arachidonic acid and its metabolites (prostaglandins; leukotrienes) 2) Platelet activating factor (PAF) 3) Tumor necrosis factor (TNF) 4) Interleukin-1 (IL-1) 5) Plasminogen activator Sites of Action of Glucocorticoids in the Responses of Leukocytes During Antigenic Challenge/Inflammation Image of Glucocorticoids removed Glucocorticoids Clinical Uses of Glucocorticoids Steroid Therapy: Routes of Administration • Systemic Oral Parenteral • Topical • Inhalation Clinical Uses of Glucocorticoids • Replacement therapy • Anti-inflammatory effect • Immunosuppression • Androgen suppression Glucocorticoids: Use as Anti-Inflammatory Agents Severe RA of hands Source: Undetermined Emily Janz, a 36-year old woman presents with a 3-year history of rheumatoid arthritis. The disease has been progressive with involvement of PIP joints in both hands, wrists, elbows and TM joints. Treatment with non- steroidal anti-inflammatory drugs (NSAIDs) has not been successful. Treatment with prednisone is begun using an alternate-day program. Glucocorticoids: Use in Immunosuppression CC-BY-ND 2.0 BY: wolfpix A 25-year old man was walking through a field when he was stung by an insect. He developed generalized edema, dyspnea, wheezing and dizziness. He was rushed by a friend to the emergency room, where a diagnosis of anaphylactoid reaction to insect bite was made. He received a large dose of steroids parenterally and was subsequently advised on a program to taper the steroids over the next one week. Glucocorticoids: Use in Immunosuppression Heart James Allen, a 55-year old man with a history of ischemic cardiomyopathy develops increasingly severe congestive heart failure. When he becomes totally incapacitated with a life-expectancy of less than 6 mo., he is placed on the cardiac transplantation list. Two months later, he receives a heart and is subsequently placed on an immunosuppressive “cocktail” that includes prednisone, 5 mg daily. Glucocorticoids: Use in Androgen Suppression Hirsutism in a young woman CC:BY-NC-SA BY: C. Matthew Peterson, MD A 25-year old woman comes in for evaluation of hirsutism present over the past 3 years. The hirsutism is of the androgen type and is associated with acne and irregular menses. Diagnostic studies reveal elevated serum dehydroepiandrosterone (DHEA) and testosterone levels. She receives Dexamethasone 2.0 mg daily, for seven days and serum DHEA and testosterone levels are measured the 8th day. Adrenocortical Hormones = Steroids GLUCOCORTICOID MINERALOCORTICOID Cortisol Aldosterone cortex medulla Adrenal Effects of Mineralocorticoid on Renal Tubule Prototypical mineralocorticoid = Aldosterone Image removed Aldosterone increases sodium resorption and potassium and hydrogen ion excretion. Prototype of Steroid Compounds Source: Undetermined Steroids: Structure-function Relationships A. Hydrocortisone B. Prednisone C. 9--Fluorocortisol Source: Undetermined • Double-bond in 1,2 position increases glucocorticoid activity. • Fluoro- group in 9-a position increases mineralocorticoid activity. Steroids Compound Anti-Inflam. Na-Retain. Duration of Equivalent potency potency action Dose Cortisol 1 1 Short 20 mg Prednisone 4 0.8 Intermediate 5 mg 9--fluoro- 10 125 Short * cortisone Dexa- 25 0 Long 0.75 mg methasone Glucocorticoid effects: Dex > Prednisone > Cortisol Mineralocorticoids: 9--fluorocortisone RULES Glucocorticoid Therapy Side Effects Or “Yes, Virginia, there can be at times ‘Too Much of a Good Thing…’” Glucocorticoid Effects on Calcium & Bone STEROIDS “BRITTLE BONES” Osteoblastic activity Calcium absorption from gut. PTH secretion Osteoclastic activity Steroids “Brittle Bones” A 60 yo postmenopausal woman was seen in clinic with acute onset of mid-thoracic back pain. She had complained of back pain for the past 2 years and a 2” loss of height. She had been on Prednisone, 10-15 mg daily, for the past 5 years for chronic polymyositis. Radiographic exam of the spine shows compression deformities in several vertebral bodies. CC:BY-NC-ND 2.0 BY: Wellcome Images Public Domain NIH Chronic Glucocorticoid Therapy & Carbohydrate Metabolism GLUCOCORTICOIDS (+) BLOOD (-) Liver GLUCOSE (-) MUSCLE (+) INSULIN Chronic glucocorticoid therapy may “unmask” diabetes in genetically susceptible individuals. FAT CELL Glucocorticoid Effects on the Central Nervous
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